New Jersey Hair Restoration - NJ Hair Transplant Q&A
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Q: I have a bald patch on my scalp diagnosed as DLE, can this be corrected with a hair replacement procedure? L.K., Tenafly, New Jersey
A: DLE or discoid lupus erythematosus is a type of autoimmune disease where the body produces an inflammatory reaction to components of the skin, causing it to scar and loose hair. The skin in the area of hair loss generally has a smooth appearance with tiny empty hair follicles, redness, and altered pigmentation. These skin changes help to differentiate it from the more common condition alopecia areata where the underlying skin appears normal. The diagnosis of DLE can be confirmed by biopsy. Because DLE may exhibit a property called Koebnerization, where direct trauma can make the lesions enlarge, surgical hair restoration risks making the condition worse and is, therefore, not indicated.
Q: When a donor strip is taken out during a hair transplant surgery and separated under the microscope, you can read on the internet that there is a wastage of grafts (about 15%), because of those unseen telogen hairs. What do you think about that and how does it affect the hair restoration? M.L., Union City, New Jersey
A: The Telogen phase of the hair cycle is about 3 months long and about 12% of follicles are in this phase at any one time. It is speculated that the follicles may be empty for perhaps 1/2 that time (this number may vary significantly between people). Therefore, approximately 6% of the hair follicles may be in telogen at any one time.
On average about 15% of the follicular units are 1-hair units (but this also may very greatly between patients). If 6% of all follicles are “empty” telogen follicles, then there should be .15 x .06 = .009 or 1% of the patient’s 1-hair follicular units in the empty telogen phase that can't be identified and that will be missed on dissection.
The 1% isn't very large; however, also consider that the remaining 5% of the empty follicles are associated with larger follicular units (i.e. those with 2-4 hairs). If these follicular unit grafts are closely trimmed, as is the practice with very dense packing, a much more significant number of follicles are at risk of being lost. With chubby follicular unit grafts (i.e., where the microscopic dissection leaves a protective sheath of tissue around the follicles) the risk should be closer to the 1%.
The lesson for hair transplantation is that over-trimming of grafts, for the sake of very dense packing, may waste telogen hairs, as well as place the grafts at an unnecessary risk of mechanical trauma, drying and warming.
Q: I am Norwood Class 6 and have read about both FUE and FUT. Which will give me more hair? J.H. Englewood, N.J.
A: In general, FUT will give you more hair since, in FUT, the best hair from the mid-portion of the permanent zone of the scalp (also called the “sweet spot”) can be utilized in the hair transplant surgery. With FUE, since only the hair follicles are extracted and not the surrounding bald skin, if too much hair is removed, the donor area will begin to look thin as hair is removed. This will limit the amount of hair that can be harvested. Although in FUE additional areas of the scalp can be utilized to some degree, this will generally not compensate for the inability to access all of the hair in the mid-permanent zone and the total amount available for the surgical hair restoration will be less.
Q: Will the shock of a hair transplant make me lose my existing healthy hair and is it permanent? J.Y. - Union City, N.J.
A: In general, only miniaturized hair (the hair that is affected by androgens and that has begun to decrease in diameter) is shed after patients have hair transplants. This hair would be lost in the near term anyway. Existing, healthy hair is unlikely to shed, but if it were shed, you could expect it to grow back.
Q: When performing a repair on an old, pluggy hair transplant, why can’t all the grafts be removed at once? E. K. – Bergen County, New Jersey
A: We always try to do this, but it is not always possible during hair restoration surgery. If the large grafts (plugs), are spaced too close together, suturing one will put tension on an adjacent graft and make it more difficult to close. This may worsen, rather than improve, the underlying scar. In addition, it is not always possible to remove all the follicles in a graft on one pass (as the root tends to fan outward deeper in the skin). If you use a large enough punch to remove all the follicles at once than you risk leaving a mark from the excision. For more details, please read the following papers about hair transplant repair:
http://www.bernsteinmedical.com/resources/publications/ArtRepair1-2002.php
http://www.bernsteinmedical.com/resources/publications/ArtRepair2-2002.php
Q: Are camouflage agents harmful to newly transplanted follicles after a hair restoration? LJ – Trenton, New Jersey
A: Cosmetic camouflage products are not harmful to grafts per se, but they may make it difficult to keep the transplanted area clean right after the surgical hair restoration procedure. They may be used safely as early as one week following a hair transplant, since at this time they can be gently washed out without disturbing the newly transplanted grafts. These hair replacement products are useful in reducing any residual redness and can make the transplanted area appear fuller until the new grafts grow. There are a number of products that can be used – they come in a variety of forms i.e. creams, sprays, powders and gels. To find out where to get them, go to the Camouflage page in the Medical Treatments section of our site.
Q: If a second hair transplant is performed before the first had a chance to grow could the second procedure destroy the follicles from the first? T.H. – Englewood, NJ
A: Hair from the second hair transplant session would not damage the follicles transplanted in the first session, even if follicular unit grafts were transplanted in exactly the same spot as in the first session. The reason to wait until the hair grows in, however, is so that you can better plan the subsequent hair replacement surgery. If two follicular units are placed on top of each other or very close together, you will essentially be creating a mini-graft and the results will not look natural. We advise waiting at least 8 months between sessions with 10-12 months being ideal so that the grafts of the second session can be evenly distributed among the grafts of the first. The extra few months not only allows the hair restoration doctor to identify all of the previously transplanted grafts, but enables him to get a sense of the “look” of the first session i.e. the wave, the density, and how the patient will ultimately want to comb his newly transplanted hair. This is very useful in guiding the placement of grafts in the second session to maximize its cosmetic benefit.
Q: Why does a hair transplant work? W.C. – Teaneck, NJ
A: Hair transplantation works because hair taken from the permanent zone in the back and sides of the scalp maintains its original characteristics when transplanted to a new place in the balding area in the top of the head. This property of hair is called “donor dominance.” The hair follicles in areas that go bald are genetically susceptible to DHT, a breakdown product of testosterone. In response to DHT, these hair follicles miniaturize (decrease in size) until they eventually disappear. When follicles from the permanent zone, that are resistant to the effects of DHT, are moved to a balding area during a hair restoration surgery, they maintain this property, and continue to grow.
Q: What is your opinion on having a hair transplant to restore the hairline and then wearing a hair system behind it to regain the appearance of a full head of hair? K.Y. – Hackensack, New Jersey
A: It is my personal feeling that one should not use hair replacement surgery to supplement a hair system, especially at a young age. We have occasionally performed this procedure in older men and women. In my view, a main purpose of a hair transplant is for it to be low maintenance. The combination of surgical hair restoration and a hairpiece is extremely fussy. In addition, hair systems cause traction alopecia (hair loss from constant tugging) and the hair loss will become permanent over time, limiting the ability to have hair transplants in the future. If one needs to have the high density of a system i.e. for a career, then just use the system. It will give you more long-term options.
Q: What are your recommendations for wearing a hairpiece following a hair transplant? Philadelphia, Pennsylvania
A: First some clarification. It is OK to wear a “hair piece” (one that is attached to the hair with clips or to the scalp with tape) so that it can be removed each night, but NOT a “hair system” (that is woven to existing hair or glued to the scalp) and must be removed by the salon. Patients should wait a week before they resume wearing their hairpiece, although some patients use it as soon as two days later (but keep it on for very short periods of time). After the first week, I don’t have any restrictions with regard to duration during the day, as long as the person removes the hairpiece at night and shampoos the scalp thoroughly at least once a day. The hairpiece should be kept clean and it helps if the person has a spare. The piece should be attached with clips. A stiffening rod can be inserted along the front edge to keep it from lifting up. One should avoid using glue. Tape can be used in conjunction with clips only if the area of attachment of the tape is away from the implanted grafts.
Q: Should you perform a hair transplant on a crown that is just starting to thin? G.K. – Englewood, NJ
A: A “thin” crown should first be treated with Propecia, as it may thicken the hair to a cosmetically acceptable degree without the need for hair transplant surgery. If Propecia is ineffective in restoring enough hair, then hair replacement surgery can be considered. The hair transplant doctor must also factor whether or not the patient has enough donor reserves to transplant the front and top part of the scalp if the patient becomes very bald. This is hard to predict in patients who are still in their twenties. See the paper Follicular Transplantation: Patient Evaluation and Surgical Planning for more a more complete discussion.
Q: Is it possible to do a hair transplant using follicular unit extraction without shaving the donor area? J.G. – Paramus, New Jersey
A: In follicular unit extraction, the area that is extracted is clipped to about 1-mm in length. However, if the session is not too large, then the clipped area can be long and thin so that the patient’s existing hair will cover it. The person’s hair should be left long for the hair restoration surgery.
Q: Why can donor hair become frizzy and dry once transplanted? Y.W. – Bergen County, NJ
A: Frizzing and kinkiness is a temporary phenomenon that is part of the normal healing process after a follicular unit hair transplant. During the healing process, the new collagen that forms around the grafts can alter their growth. Over time, usually a period of a year, this collagen matures and the hair quality usually returns to normal. If grafts have been excessively traumatized or grafts larger than follicular units have been used, these changes are more likely to be permanent.
Dry hair is felt to be caused in part by trimming follicular units too closely and thus removing the sebaceous glands which normally provide an oily film to the surface of the hair and skin. With grafts smaller than follicular units, i.e. with closely trimmed micro-grafts, the risk is even greater. To prevent this, in the dissection phase of the hair replacement procedure, one should isolate intact follicular units from the donor tissue and trim away excess skin, but not trim the follicular units “to the quick.” Excess trimming, besides removing the sebaceous glands, also makes the grafts more subject to drying, warming an mechanical trauma (particularly during graft placing).
Q: What are "Senior Medical Consultants”? P.L. – Englewood, NJ
A: These are non-medical personnel who wear white coats to give the impression that they have formal medical training. They are actually salespersons and they should immediately identify themselves as such. Although non-medical personnel can help to answer general hair replacement questions, they should not be examining you and making specific recommendations about your procedure - that is the job of your surgical hair restoration doctor. When a physician evaluates you and makes recommendations, he/she is responsible for informing you of the risks as well as the potential benefits of your surgery, and is ultimately responsible for your care. He will also have the knowledge to provide you with a balanced view regarding your surgery as well as other treatment options. This is the practice of medicine! A "consultant´" who is being paid to convince people to have hair transplant surgery, but who is not actually performing the procedure, does not bear this responsibility, and may have a natural tendency to over-sell the procedure. Beware!
Q: Can hair transplants grow in scars? C.M. – Short Hills, New Jersey
A: Grafts will grow in scar tissue as long as the scar is not thickened. However, they cannot be placed as close together as in normal scalp because of decreased blood flow. When performing a hair transplant into scar tissue, it is often necessary to perform the hair restoration in multiple sessions to allow the area to gradually re-vascularize (allow the blood supply to return).
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Q: Can a hair transplant into bald areas caused by alopecia areata ever be successful? T.S – Fort Lee, N.J.
A: Alopecia areata is an autoimmune disease in which the body attacks its own hair follicles. It generally appears as round patches of smooth bald areas scattered in the scalp or beard. Less commonly, it can involve the entire scalp (alopecia totalis) or all facial and body hair (alopecia universalis). Unless the condition is well localized and totally stable, hair transplantation is not likely to be effective because the transplanted hair would be subject to the same problem. We prefer that one have no new lesions for a minimum of two years before considering surgical hair replacement; although this does not insure that the procedure will be successful. You may find more information on this relatively common condition at the national alopecia areata foundation: www.alopeciaareata.com or www.naaf.org.
Q: Over the years, I have worn my hair in braids and extensions. My hair is not growing at my hairline and temples. Can the braids be the cause and can this be treated with hair transplant surgery? C.C – Newark, NJ
A: The name for hair loss is this area is called alopecia marginalis. It is almost invariably caused by continued traction from braids or hair extensions. When this is the case, the condition is also called traction alopecia. If the problem is long-standing, the hair will rarely come back, even if the braiding is stopped and a hair transplant would be indicated. If there is enough hair loss on the sides of the scalp that the donor supply is significantly reduced, surgical hair restoration may not be possible.
Q: What exactly is compression in a hair transplant? H.T – Englewood Cliffs, New Jersey
A: Compression refers to the visible tufting of grafts due to the contraction of the grafts from the normal elasticity of skin around it, after it has been inserted into the recipient site. Compression is most commonly seen when minigrafts are used in the hair restoration (minigrafts contain more than four hairs each). Follicular units don’t show visible compression, since they are already naturally compact. However, if more than one follicular unit is placed into the same site, it can exhibit this phenomenon. Compressed grafts will become less visible as more hair is transplanted to the area, but if they are close to the hairline or in areas where a lot of density may not be planned (such as in the crown) they may have to be removed. In this case, they can be placed under a microscope, divided up into smaller grafts and re-implanted.
Q: I have had some grafts implanted into a donor scar. How long does it take to see the final result? S.K. – Fort Lee, New Jersey
A: In normal scalps, growth is generally complete by 10-12 months. Grafts placed in scar tissue may often take longer to grow.
To read more Q & A’s with Dr. Bernstein or to view questions by category, visit our hair transplant Blog
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